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Chapter 23 Health Records and Hea l th Information Manag e ment

Chapter 23 Health Records and Hea l th Information Manag e ment. Health Inf o rmation Mana g ement. All h ealt h c a r e providers, regardless of setting , are r e quired t o maint a in all patie n t c a r e information th a t applies t o an individual patient.

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Chapter 23 Health Records and Hea l th Information Manag e ment

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  1. Chapter23 HealthRecordsand Health Information Management

  2. Health Information Management Allhealthcareproviders,regardlessof setting,are requiredtomaintainallpatient careinformationthatappliestoanindividualpatient.

  3. Health Information Department Functions • Supportthe currentandcontinuingcareofpatients • Supportthe institution’sadministrativeprocesses • Maintainrecordsforpatientbilling/accountingprocesses • Supportmedicaleducationprograms • Supporthealthservicesresearch • Maintainrecordsforutilizationmanagement,riskmanagement,andqualitymanagementorperformanceimprovementprograms • Ensurepatientprivacy andsecurityissues • Ensurecompliancewithlegalrequirements • Performotherextraneouspatientservices

  4. What’s in theHealthRecord? According toTJC Amedicalrecord mustcontainsufficientinformationtoidentifythe patient,supportthe diagnosis,justify the treatment,documentthe courseandresults,andpromote the continuityofcareamonghealthcareproviders. Accordingto Medicare …the medical record must containinformationtojustifythe admissionandcontinuedhospitalization,supportthediagnosis,anddescribe the patient’sprogressandresponseto themedicationandservices.

  5. Health Record Content • Standards forthe maintenanceandthe adequacyof healthrecordshavebeenestablishedby accreditingagencies suchasTJC(JCAHO)or HFAP • Givesability totrackdata overtime • Alldepartmentsthattakepartinthe careofa patient • mustdocumentthatcareinthehealthrecord • ChartingDocumentingin thepatient’srecord • Shouldbedonewhenapatient receiveseitherdiagnosticor • therapeutic radiologicservices • If itisn’t documentedinthe chart,itwasn’tdone!

  6. Health RecordInformation • Treatmentplan • Evidence of informed consents • • • • • • • • • • • • • • • • • PatientIDanddemographics • Medicalhistory • Psychological needssummary • Physicalexamreport • Clinical observations • Progress notes • Consultationreports • Diagnosticandtherapeuticreports • Diagnosticandtherapeuticordersincludingmedicationservices Reportsofsurgical/invasiveprocedures Recordsof donationsandimplants Impressionuponadmission FinaldiagnosisandprognosisConclusionsat termination of stay Dischargeinfogivento patientandfamily DischargesummaryPostmortemresults

  7. Traditional HealthRecords: • Paper-basedmedicalrecordsystem • Practitionerstorestest results/notesfromeachpatient • consultationin a “patientchart” • Chartsarecreated/storedin eachdistincthealthcare • locationER, physician's office,hospitalfloor,radiology… • Records can be misfiled,lost, ordestroyed • Lackofcommunicationcancauseerrors • Eachpractitionerhasptinformation vitalto properdiagnosis • Chartisthelegaldocument

  8. Storage • Paper-basedmedicalrecordsystem • Chartsmorethan7 yearsoldarepurged-legally • "inaccessible" • Storageoffilmrequirementsbylegalprecedent! • Keepfilm 5–7years • Pediatric andlitigationfilms storedindefinitely! • Needsignificantamountofspace

  9. WhatisanElectronicMedicalRecord? • Computerizedmeansofstoringpatient'shealthdata • Allowsfordigitalorderentry andmanagement • Allowsforcommunication/connectivitywithotherdepartmentsorproviders • Stores patient’shealthdata indefinitely • Electronicdata canalmostalwaysberecovered • Canbeaccessedfromanywhere • Datais “searchable” • Metadata ElectronicHealthRecord– longitudinalelectronicrecordof patienthealthinformation

  10. Storage:

  11. Rules forthe Health Record • Mustbecomplete! • Readilyaccessibletoanyonewhohasarightto • theinformationandtheneedtouseit • Canbeusedforpatientcare,forhospitalstatisticsandresearch,andforactivitiessuchasquality managementandriskandutilizationmanagement • Radiologymakerequestsfordatausedforadministrative,research,andappliedhealth informaticsactivities • Hospitalsandothertypesofhealthcarefacilitiesneedhigh-qualityhealthcaredataforoperations

  12. Health Information Terminology • APC—AmbulatoryPaymentClassification • BasedonICD-9-CMcodesfordiagnosisand CPTcodesusedforreimbursementtohealthcareinanoutpatientsetting • CPT—CurrentProceduralTerminology • Listingofmedicaltermsandcodesfordiagnosticandtherapeuticproceduresusedfor codingforphysicianreimbursement(usedforbothinpatientandoutpatient)

  13. Health Information Terminology • ICD-9-CM—International Classificationof • Diseases,9thedition,ClinicalModification • UniversalclassificationsystemusedthroughouttheUnitedStatesandworldforcodingandreportingproceduresanddiagnoses • DRG—Diagnosis-RelatedGroup • Categorizesintopaymentgroupspatientswhoaremedicallyrelatedwithrespecttodiagnosis andtreatmentandstatisticallysimilarwith regardtolengthofstay

  14. Health Information Terminology • TJC—TheJoint Commission • FormerlyJointCommisiononAccreditationofHealthcareOrganizations(JCAHO) • Organizationthataccreditshospitalsandother • healthcareinstitutionsintheUnitedStates • PPS—ProspectivePaymentSystem • SystemforMedicarehospitalinpatients wherebypaymentgroupsareestablishedin advance;hospitalsgetpaidupfront

  15. Health RecordReimbursement • Medicalrecordscontainsufficientinformationto supportthediagnosisforreimbursement purposesundertheDRGandPPSimplemented bythegovernmentin1983 • Codingofanimagingprocedurerequiresoneor moreprocedural(CPT)codesandoneormorediagnostic(ninthrevisionofICD)codes • Correctcodingiscriticaltoreimbursementandfinancialhealthoforganization • Exactmatchiscrucial!

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  17. For the Technologist: • NeedanexactmatchofCPTcodetotheactual • procedureperformed • Specificexam (includingviews) • Contrastadministered? • Accessoriesrequired? • Abdomen/PelvisCTfor Kidney Stones • Abdomen/PelvisCTfor Bony Injury • Abdomen/PelvisCTwithcontrast forAppendicitis • Abdomen/PelvisCTwith contrast forAbdomenpain • Abdomen/PelvisCTwith contrastRoutine • Abdomen/PelvisCTwith contrast forOncology • ETCETCETC

  18. For the Radiologist: • NeedaspecificdxinordertomatchtheICDcodewithCPTcodeforreimbursement • Results thatare“normal”or“withoutsubstantialfindings”canbe codedonlywiththe suppliedclinical information • + studyfindingsallowthe codertorefine dx • Chestpain,unspecified- ICD-9 code786.50whichmay notbea • reimbursableICD-9code • Pneumothoraxallowsspecificcodingofsecondarydx (primarydxremains“chestpain”)ofICD-9 code512,which typicallyallows reimbursement

  19. What about Informed Consent? • RequiredbyTJC • The policyon informedconsentistypicallydevelopedbythe medicalstaffandthehospitalgoverningboard,consistentwithlegalrequirementsforappropriateinformedconsent • Informedconsentimpliesthatthe patienthas beeninformedofthe procedures oroperationto be performed,ofthe risksinvolved,andofthe possibleconsequences • By signingthe consentform,the patientorthe patient’srepresentativeindicatesthatheor shehas been informedofand consents to theprocedureortreatment

  20. Informed Consent • NotthesameasanAuthorizationforTreatment • Iftheinformedconsentisnotfiledwiththemedicalrecord: • The recordmustthenindicatethatan informedconsentwasobtainedforagiven procedureortreatment • The recordmustindicatewhere the informedconsent • formislocated

  21. Incident Report • Contains information relativeto patient incidences oroccurrencesthatareoutofthenormalexperience • Incidencebeclassifiedassentinelevent • Mustbe completedafter anevent

  22. What doesthishave to dowith Radiology? • Weuse theHealth Recordineverythingwe do! • Beforearadiologicprocedureisperformed,aradiologyorderor requestforserviceis completed • Adiagnosisorsignorsymptomforwhichthe testis beingperformedmustaccompany eachrequest. • Resultsoftheproceduresent to HealthRecord • Anyspecialreports documentingevaluationor treatmentofa patientmust be madea part ofthe patient’spermanentrecord

  23. Howdo we get PatientInfo? • HospitalInformationSystems(HIS) • Databasecontainingallpatientmedical recordinformationexceptfor radiology • HIS registerspatients andsendsorderstoRIS • RadiologyInformationSystems(RIS) • Radiologyspecificdatabase • RISgeneratesexamination worklist– senttomodalities • RISthensendspatientinformationtoPACS • PictureArchivingandCommunicationSystem (PACS) • Hardwareandsoftware-imagesin electronicform (DICOM) • Integrationof theEMRwithRadiologyInformation System(RIS) • EMRinfotransferredfromHospital InformationSystem(HIS) • PACSsendsimageandpatient datatoradiologistor clinician

  24. HIS/RISIntegration 24

  25. Exampleof Workflow • Step1:IDENTIFY–PATIENT • Step2:VERIFY – ORDER • Step3:BEGIN– ProcedureinRIS cancelorchangeanyexam infoasnecessary. • Step4:SCAN– Perform Procedure • Step5:STOP– Re-Verify PatientInfoandeditas necessary,beforesendingtoPACS • Step6:SEND EXAM– toPACS • Step7:SCAN DOC-to PACS • Step8:CHECK–Images onPACS • Step9:END– ProcedureinRIS

  26. RadiologyWorklist-Example

  27. RadiologyRequest-Example

  28. RadiologyRequest-Example

  29. RadiologyRequest-Example

  30. What else is in the HealthRecord?

  31. Standards • DigitalImagingandCommunicationinMedicine • Standards-basedprotocol(computerlanguage)forexchangingandstoringmedicaldata(images andtext) • aroundtheworld • HL-7 • Comprehensivelanguageframeworkforhealthinformation allelectronic • GivesinteroperabilitybetweenEMR,PACS,and otherelectronicplatforms

  32. Case-Confidentiality • RTworkinginprivateofficerecognizesapatient assomeonesheknewinhighschool • RToverheardco-workersdiscussingpatient’sreasonfortreatment(STD)–patientdidnotneed anyradiologicexams • RTlookeduppatient’sinfoinEMRandemailed • specificsaboutthecasetoseveralofherfriends

  33. What isHIPAA? • Originallypassed to helpfamiliescarryhealth • insurancethroughjob transitions • As ofApril2003,all HCPswhotransmit medical informationelectronicallyhaveto beHIPAAcompliant • Patients havethe righttoprivacy andconfidentialityabouttheircare,diagnosis,andmedicalinformation • HIPAAgivesspecificrulesandregulationsaboutprivacyandsecurityofpatientpersonalhealthinformation

  34. What isPHI? • PersonalHealthInformation • ANYinfothatcouldidentifyorcouldbeusedto identifyanindividual • ANY healthinformationrelatingto: • Past,present,or futurephysicalor mentalhealthorcondition • Provisionof healthcare • Past,present,or futurepaymentfor healthcareservices • Verbal,Written,orElectronic

  35. Security • HIPAArulesaresame forEMRsasforPaper Records • Permissionto Access,Use,orDisclose PHIisalwaysdeterminedbyPURPOSE • Every time PHI accessed-mustbepermittedby HIPAAAuthorization,Waiver, ReviewPreparatory toResearch,Review ofDecedent Information,LimitedDataSet • Justbecausea cliniciancan accessand runreports from • EMRsdoesn’t mean they’repermittedtodoso WhatdoyouthinkhappenedinourCase?

  36. Ownership of MedicalRecords • Caregiverorfacilityownstherecords • Patienthastherighttotheinformation includedinthereportexceptwhereprohibitedbylaworthepatient’smedicalcondition.

  37. Legal Aspects ofHealthRecords • Healthrecordsare consideredlegaldocuments. • Radiologictechnologistsmaybe requiredto give depositionsor testimonyregardinginformationin thehealthrecordor,in the caseofaradiograph,testimonyregardingthe proceduresinvolved. • Howdo youcorrectanerror? • Theauthordrawsa singleline throughthe error(strikethrough), • write“ERROR,”andthenrecordthecorrect information. • Theindividualthenshoulddateandauthenticatethe entry.

  38. Legal Aspects ofHealthRecords • Healthrecordsareconsideredtobeconfidential. • Theoriginalrecordisneverleftincourt. • Informingpatientsofexamresultsisthephysician’sresponsibility,andthetechnologistshouldreferthepatienttohisorherphysician. • HIPAAclearlyoutlinestheconfidentialityrequirementsofhealthrecords.

  39. MedicolegalIssues with EMR • Errorsleadtolawsuits! • ImplementationofEMRsmay increasethe numberof • medicalmalpracticesuits • Raisesthestandardofcareforpractitionersandthehealthcarefacilitieswheretheypractice • Metadata • NOCopying/pasting • DocumentnotesonEVERYTHING! • Thoroughpatienthistoryeverytime! • Not justcopy+paste

  40. How Did They Find Out? • UCLAMedicalCenter • Imposeddisciplineactionsagainst13employeeswholookedat BritneySpears’medicalrecords withoutpermission • AnalysisofEMRmetadataallowedUCLAMedicalCentertodiscoverwhichofitsemployeeswere"snoopingin“ Britney’smedicalrecords

  41. What is Metadata • Dataaboutthedata • Automaticallygeneratedcomputerrecordthat certifieshowanelectronicdocumenthasbeen manipulated • AudittrailregardingPACS/EMR usage • Oftenwithoutuser’sknowledge • Systemvs Application WewilltalkmoreaboutthisinMedicalLaw

  42. PerformanceImprovement • AKAQualityAssuranceorQualityAssessment • Aprocessthatmonitorsandevaluatesthequalityofthecareandservicesprovidedtopatientswithinahealthcarefacility • Includes many measurements • Qualityimprovementprograms • Benchmarks

  43. Best Practices • ThinkWork Flow! • Verifypatientinfobeforeexam • DocumentnotesonEVERYTHING! • Thoroughpatienthistory– notjustcopy+ paste • If studyisdelayed,annotatewhy,when,andhowlong • Documenteverythingrelatedto contrastmedia! • Trackprocedures atactualtimeofservice • Useleadradiographicmarkersinsteadofdigitalmarkers • Check previousexams– ethicalduty! • Ifglitchoccurs, informadminrightaway!

  44. RecordingInformationin the MedicalRecord Do Writeortypelegibly If writing,useink;BlackpreferredUse correct spellingandstandardabbreviations Writeaccurateinformation, preciselyandcorrectly Keepinformationconcise Begineachentrywiththedateandtime (military)of the entry Record theinformationasitoccurs Keepinformationconfidential Signeach entry with yourname andtitle • Don’t • Writeinpencil • Blockoutor eraseentries • Enterunnecessarydetails • Include criticalcommentsaboutthepatientorother health careprofessionals • Leaveblankspaces inyournotes • Useimproper abbreviations • Record information for someone • Divulgeinformationconcerningthepatient • Useinitialswhensigningyour       else    name

  45. Any Questions?

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